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Forms > 07 Household Maintenance (76 docs)

07 Household Maintenance (76 docs)

Free Forms, caregiving, nursing forms, policies, Licensing, Training, Case Management, Home Care, Assisted Living, DD, MI, HCBS

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Documents in 07 Household Maintenance (76 docs) (76)

Replacement log form. AC Filter Replacement Log
A form used in community based care homes and various types of assisted living facilities to report accidents, incidents, and/or injury to an employee. Accident Incident Injury Report Form - Employee
A form used by a care facility, or at a person's home to check areas of the facility for possible safety issues for residents with Dementia and/or Alzheimer's disease. Good for safety prevention measures for alzhimer's care. Alzheimer's Safety Check List for Nursing Homes, Residential Care Facilities, Home Care
A detailed check list of specific areas to be visually inspected annually, ie. fire alarm and emergency systems, atmosphere control, plumbing systems, electric systems, dietary services, building, interior, exterior, yard maintenance, equipment and replacement schedules. Annual Maintenance Check & Service
Form used to complete quarterly automobile safety inspections. Auto Safety Quarterly Inspection
Form for documenting procedures when handling bath linens and precautions Bath Linen Laundry Procedures
Form used to document instructions for handling bed linens, washing, drying and precautions Bed Linen Laundry Procedures
Building specs form Building Specs
A free form to be completed when inspecting a facility Bus/Truck on a monthly basis. Bus/Truck Maintenance & Safety Inspection
This form is used to report exposure to any pathogens, such as blood. Care Facility Exposure Report Form
This form is used with all new employee's, and is completed by checking off all areas that the employee has been trained in regarding safety. Care Facility Staff Safety Training Check Off List Form
This form is used to schedule cleaning tasks, what to clean, when to clean, who will clean, etc. Cleaning Schedule
Contact Numbers form. Contact Numbers Vendors and Supplies
Form for residents to rate their laundry service. Customer Service Survey - Laundry
Handbook responsibility sign page. Designation of Maintenance Policy Handbook Responsibility
Communication and suggestion form used by employee's regarding unsafe conditions and/or occupational health concerns. Employee Safety Communication and Suggestion Form
Form used by an employee to assess their ability to lift. 

In order for the facility to better assign lifting tasks to individuals who are able to perform the job, we require each employee to complete this form.
Employee's Name:	
Facility Name:
To Whom it May Concern,
I understand one lifting standard does not fit all persons, due to size, weight, height, and physical strength that it is my responsibility to ensure for my self-safety.  I know I can safely lift: Ergonomics Self Verification Form
Form to draw facility floor plan for licensing purposes. Facility Sketch
Fall prevention and safety check list to audit your facility or residential care home. Fall Prevention and Safety Check Off List for care facilities and assisted living communities
This fire drill evaluation form is used by the care home staff to evaluate how they performed during a fire drill. Good for assisted living facilities, group homes and residential care homes.

Was the local fire district notified that you are going to be conducting a drill?
Was your alarm monitoring company notified of the fire drill?
Emergency Phone Number called? (fake one)
Portable telephone or cell phone taken to re-grouping area?
Was fake fire found, and residents removed from danger, first aid administered? ...... Fire Drill Evaluation
Free CARE Equipment Safety Checklist Free CARE Equipment Safety Checklist
Form for listing specific laundry instructions and precautions General Laundry Form
This form is used to report and document any hazardous situation. Hazard Report Form
This form is used to train the staff regarding hazardous chemicals that may be found in the workplace. Hazardous Chemical Training
Form used to document handling of housekeeping linens Housekeeping Laundry Procedures
This form documents the person responsible for maintaining the policy and procedures covered in the housekeeping handbook. Housekeeping Policy Handbook Designation
Form for checking to make sure housekeeping staff are properly trained in various area to assist with compliance. Housekeeping Staff Check List
Master list of maintenance services. IIPP Master List Maintenance Services
A form used to track communication and phone calls regarding incidents that concern the care business or care facility in general. Incident Call and Communication Log - Company
Independent Contractor Agreement Form. Independent Contractor Agreement
Independent Contractor Agreement sample to show how the form should be completed. Independent Contractor Agreement (Sample)
A thorough form covering payment, schedules, services to be performed, contractor tax identification number, etc. when using an Independent Contractor in your organization. Independent Contractor Questionnaire
Before hiring an Independent Contractor to do maintenance at your Residential Care, Assisted Living, or Nursing Facility, have them complete this simple form.  It contains a checklist of all the various maintenance jobs that need to be completed. Independent Contractor's Skills and Abilities
Form for completed tasks. Job Completed Report
Description of job duties and responsibilities of a housekeeper in a care facility.  

The Challenges
~Compliance with all the rules and regulations at all times.
~Legally responsible for carrying out the businesses established policies and procedures pertaining to housekeeping.
~Cleaning toilets.
~Cleaning incontinent residue. Job Description - Housekeeper
Overview of responsibilities of the laundry supervisor Job Description - Laundry Supervisor
Description of the job duties and responsibilities for a facility maintenance supervisor of a care facility.  

The Responsibilities
~Use universal precautions.
~Must report safety issues.
~Mandated Adult Abuser Reporter.
~Must leave work areas free from hazards.
~Complete repairs and assignments in a timely manor. Job Description - Maintenance Supervisor
This is a form listing job tasks that may be encountered which will place care facility staff at risk of occupational exposure to blood or other potentially infectious materials. Job Exposure Determination - Care Facility Housekeeping
This is a form used to list job tasks that may be encountered which will care facility place staff at risk of occupational exposure to blood or other potentially infectious materials. Job Exposure Determination - Care Facility Maintenance
Job form. Job Inquiry Form
Overview of the job duties and responsibilities of a Housekeeper in a care facility. 

General Job Duties: Keep facility clean, beautiful and free from safety hazards. Comply with all mandated laws. Job Overview - Housekeeper
Overview of the job duties and responsibilities of the Maintenance Supervisor in a care facility.  

Special Qualifications: Physical ability to handle the job. (Lifting 31 pounds) 18 years of age verification. Free of Communicable Diseases. Fingerprint - clear criminal background. Abilities to multi-task and maintain a good rapport with others. Job Overview - Maintenance Supervisor
This form is used to evaluate the employee while they are performing their normal job duties, checking to make sure safety and procedures are followed at all times. Job Safety Check List
Form for documenting washing, and drying procedures as well as precaution needed. Kitchen Laundry Procedures
Form listing the areas that need to be checked on a regular basis Laundry Check Off Form
Form used to document laundry duties. Laundry Duty List
Form designates the person responsible for the laundry handbook policy and procedures Laundry Handbook Policy Designation
Form used to document residents room, clothing,  and laundry conditions. Laundry Quality Assurance Report
Form documenting the type of laundry service the resident prefers Laundry Service Agreement Sample
Form used to document use and precautions of common laundry agents Laundry Supplies Form
Facility lighting order form. Lighting Order Form
Care Facility form for Laundry department to be used to document article that are lost or found and action taken. Lost and Found
A form used in the Maintenance Department to plan goals. Maintenance Department Goals & Plans
Checklist of documents that need to be reviewed on a monthly or quarterly basis. Maintenance Documentation Audit
This form is used to request repairs needed in the facility. Maintenance Repair Request (Form)
A verification check list of the skills and abilities needed to perform all maintenance duties. Maintenance Skills and Abilities
Work time form. Maintenance Work Time Report
Form used to document safety checks on facility automobiles. Engine fluids, lights, brakes, tires, first aid kit, and special notes. Monthly Auto Safety Inspection
A form to keep track of routine maintenance checks and services for all types of home and community based care facilities. Facility Manager's form for regular maintenance. Monthly Maintenance Check and Service
Form with emergency contact information and phone numbers to be kept in the Material Safety Data Sheets (MSDS) Binder. MSDS Emergency Contact Information
This form is used to inventory and audit chemicals used and located at the facility and to make sure there is a Material Safety Data Sheets (MSDS) on file for each chemical kept in a binder for easy reference in case of emergency. MSDS Inventory Safety Log
Form used to audit a residential care home, Skilled Nursing Facility, or Assisted Living facility's pest control policies and procedures, and pest status. Pest Control Audit
This is a form used to update your exposure plan, employees should review their Job Exposure Determination list, and add any tasks they feel places them at occupational risk. Position Input - Job Exposure Determination
Important procedures to observe. Quality Assurance Maintenance
This useful form is used to conduct a quarterly safety check of a community-based care facility and grounds.  Safety of the residents, public and staff is essential for all residential care homes, assisted living facilities, and nursing homes.

The facility must always be maintained in a clean, safe, odorless and sanitary condition.  It is the Maintenance Supervisor's job to ensure this checklist is completed quarterly.  This company's desire is to always meet the state and federal laws and regulations and exceed their standard.  Other items not included on this list might become apparent, in such cases whenever a safety issue is Quarterly Safety Management Check Off
Form used to audit the residents closets, drawers, and action taken if needed Resident Laundry - Room Audit
Form used to determine if resident can handle their own laundry needs in a community based care home or assisted living facility. Resident Laundry Assessment Form
Form used to document delivery and special procedures for a resident, for all types of community based care homes. Resident Laundry Service Form
A great form to determine potential risk to health and or body. Risk Identification Checklist
A form list of items to check to make sure a room is ready for a resident to occupy in a community based care setting, also good for nursing homes. Room Ready Check-off List
Overview of facility policy on smoking, prohibited areas and using designated smoking areas.

Smoking and using tobacco products at this facility is restricted for medical, legal and ethical reasons.  Current research clearly demonstrates that second hand smoke can be very hazardous to others. We have strict smoking guidelines.  The goal of this policy is to protect the air quality and ensure the safety of all persons who come in contact with this facility. Smoking Policy
This form is used by community based care homes, community care facilities, assisted living communities, group homes and nursing homes to conduct a spring cleaning day with the residents and staff of the care facility.  Check off list for spring cleaning. Cleaning Form Spring Cleaning List
IA list of information and links for Standard Requirements for Facility Household Managers Standard Requirements for Facility Household Managers
This form is used to determine that the care facility or care business employee understands the regulations, policy and procedures concerning Universal Precautions, Bloodborne Pathogens, and Infectious Diseases. Universal Precautions Training Check Off List for Care Facilities
This form is used during an emergency for listing utility location and shut off points, at a care facility or for a care giver providing home care.

GAS/PROPANE Shut off - Shut off the gas/propane if you smell a related odor, or if you suspect a leak. Most gas shutoffs work by turning the lever 1/4 turn, if the valve won't work call 911 and the gas company. (Follow manufacture's instructions)  Cease all operations, and have everyone exit the area immediately. Once turned off, the gas/propane company must turn it back on. Utility Shut Offs In Emergencies for Care Facilities and Home Care
A great form for organizing meetings, topics, reports, issues to discuss when having a meeting with supervisors, managers and heads of the various departments in your organization, i.e. Nursing Home, Residential Care, Assisted Living Facilities. Weekly Department Head Meeting (Form)
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